Correspondence

A Pitfall in Assessing Gastric Lymphoma after Eradication of Helicobacter pylori

N Engl J Med 1997; 336:1529-1530May 22, 1997

Article

To the Editor:

Various studies have suggested an important role for Helicobacter pylori infection in the pathogenesis of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma. These lymphomas may regress after eradication of H. pylori by antibiotics.1-3 We describe a patient in whom regression of a large infiltrating low-grade gastric lymphoma after antibiotic treatment was documented pathologically, although the macroscopic appearance of the tumor had not changed.

A 39-year-old woman with a short history of epigastric pain was admitted to our clinic in September 1993. Endoscopy revealed a 3-cm-by-2-cm polypoid lesion in the gastric fundus (Figure 1AFigure 1Endoscopic View of the Polypoid Lesion in the Gastric Fundus (Panel A) and Intraoperative Findings with Serosal Infiltration of the Tumor (Panel B).). Biopsy specimens showed H. pylori–associated gastritis and features of a low-grade B-cell MALT lymphoma. Staging procedures, including endoscopic ultrasonography, demonstrated that the lymphoma was confined to the gastric wall (stage EI2 according to the modified Musshoff staging system). After a two-week course of omeprazole (20 mg twice daily) and amoxicillin (750 mg three times daily), eradication of H. pylori was documented histologically and by means of a rapid urease test of biopsy specimens from the gastric antrum and corpus. Careful evaluation of repeated biopsies gave no evidence of persisting lymphoma, but the macroscopic appearance of the tumor was unchanged. Five months later a slightly increased depth of apparent tumor infiltration was seen by means of endoscopic ultrasonography. We therefore decided on surgery. During surgery, a solid tumor mass infiltrating the gastric serosa was seen (Figure 1B). Surprisingly, histologic and molecular analysis of the resected tumor detected no lymphoma but only extensive fibrotic alterations. Follow-up studies for three years have not indicated H. pylori reinfection or lymphoma relapse.

With few exceptions,4 lymphoma regression after the eradication of H. pylori has not been associated with mass lesions. This patient's large tumor invaded the muscularis propria and regressed with anti–H. pylori therapy as documented by careful evaluation of surgical-resection material. Endoscopy and endosonography may not be sufficient to confirm the regression of this type of gastric lymphoma.

Wolfgang Fischbach, M.D.
Rainer Engemann, M.D.
Manfred Stolte, M.D.
Klinikum Aschaffenburg, D-63739 Aschaffenburg, Germany

4 References

1. 1

   Wotherspoon AC, Doglioni C, Diss TC, et al. Regression of primary low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori. Lancet 1993;342:575-577
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   Bayerdorffer E, Neubauer A, Rudolph B, et al. Regression of primary gastric lymphoma of mucosa-associated lymphoid tissue type after cure of Helicobacter pylori infection. Lancet 1995;345:1591-1594
   CrossRef | Web of Science | Medline

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   Roggero E, Zucca E, Pinotti G, et al. Eradication of Helicobacter pylori infection in primary low-grade gastric lymphoma of mucosa-associated lymphoid tissue. Ann Intern Med 1995;122:767-769
   Web of Science | Medline

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   Weber DM, Dimopoulos MA, Anandu DP, Pugh WC, Steinbach G. Regression of gastric lymphoma of mucosa-associated lymphoid tissue with antibiotic therapy for Helicobacter pylori. Gastroenterology 1994;107:1835-1838
   Web of Science | Medline